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FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM0000001SPECIMEN ID NO.STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVEA. Employer Name, Address, I.D. No.ACCESSION NO.OMB No. 0930-0158B. MRO Name, Address, Phone No. and Fax No.C. Donor SSN, Employee I.D., or CDL State and No.D. Specify Testing Authority: HHS NRCSpecify DOT Agency: FMCSA FAA FRA FTA PHMSA USCGE. Reason for Test: Pre-employment Random Reasonable Suspicion/Cause Post Accident Return to Duty Follow-up Other (specify)F. Drug Tests to be Performed: THC, COC, PCP, OPI, AMP THC & COC Only Other (specify)G. Collection Site Address:Collector Contact Info: PhoneFaxOtherSTEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate). URINE ORAL FLUIDORAL FLUID: Split Type: Serial Concurrent SubdividedEach Device Within Expiration Date? Yes No Volume Indicator(s) ObservedREMARKS:STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITYSPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this formwas collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.XSignature of Collector(PRINT) Collector’s Name (First, MI, Last)AMPM/Date (Mo/Day/Yr)RECEIVED AT LAB OR IITF:XName of Delivery ServiceTime of CollectionPrimary SpecimenSeal Intact YESSignature of Accessioner/(PRINT) Accessioner’s Name (First, MI, Last)Primary/Single Specimen Device Expiration Date://Date (Mo/Day/Yr)SPECIMEN BOTTLE(S)/TUBE(S)RELEASED TO: NOIf NO, Enter remarkin Step 5A.Split Specimen Device Expiration Date:/(Mo/Day/Yr)STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY REJECTED FOR TESTING ADULTERATED NEGATIVE DILUTE POSITIVE for: SUBSTITUTED//(Mo/Day/Yr)PRESS HARD - YOU ARE MAKING MULTIPLE COPIESCOLLECTION: Split Single None Provided, Enter Remark.URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F? Yes No, Enter Remark Observed, Enter Remark INVALID RESULTAnalyte(s) in ng/mLVersion C 6May2020REMARKS:Test Facility (if different from above) :I certify that the specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed, and reported in accordance with applicable f ederal requirements.XSignature of Certifying Technician/Scientist(PRINT) Certifying Technician/Scientist’s Name (First, MI, Last)/Date (Mo/Day/Yr)STEP 5b: COMPLETED BY SPLIT TESTING LABORATORYLaboratory Name0000001X/Signature of Certifying Scientist////(PRINT) Certifying Scientist’s Name (First, MI, Last)Date (Mo/Day/Yr)SPECIMEN A0000001Date (Mo/Day/Yr)SPECIMEN BCOPY 1 - TEST FACILITY COPY/Date (Mo/Day/Yr)80308Laboratory Address RECONFIRMED FAILED TO RECONFIRM - REASONI certify that the split specimen identified on this form was examined upon receipt, handled using chain of custody procedures,analyzed, and reported in accordance with applicable federal requirements.

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM0000001ACCESSION NO.OMB No. 0930-0158SPECIMEN ID NO.STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVEA. Employer Name, Address, I.D. No.B. MRO Name, Address, Phone No. and Fax No.C. Donor SSN, Employee I.D., or CDL State and No.D. Specify Testing Authority: HHS NRCSpecify DOT Agency: FMCSA FAA FRA FTA PHMSA USCGE. Reason for Test: Pre-employment Random Reasonable Suspicion/Cause Post Accident Return to Duty Follow-up Other (specify)F. Drug Tests to be Performed: THC, COC, PCP, OPI, AMP THC & COC Only Other (specify)G. Collection Site Address:Collector Contact Info: PhoneFaxOtherSTEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate). URINE ORAL FLUIDCOLLECTION: Split Single None Provided, Enter Remark.URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F? Yes No, Enter Remark Observed, Enter RemarkEach Device Within Expiration Date? Yes NoORAL FLUID: Split Type: Serial Concurrent Subdivided Volume Indicator(s) ObservedREMARKS:STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITYSPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this formwas collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.XSignature of Collector(PRINT) Collector’s Name (First, MI, Last)/AMPM/Date (Mo/Day/Yr)Name of Delivery ServiceTime of CollectionSTEP 5: COMPLETED BY DONORI certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube used was sealed with a tamper-evident sealin my presence; and that the information provided on this form and on the label affixed to each specimen bottle/tube is correct.XSignature of Donor()Email address:()////Date (Mo/Day/Yr)(PRINT) Donor’s Name (First, MI, Last)Date of Birth(Mo/Day/Yr)After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may contact you to ask about prescriptions andover-the-counter medications you may have taken. Therefore, you may want to make a list of those medications for your own records. THIS LIST IS NOTNECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 5). – DO NOT PROVIDE THISINFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN URINE ORAL FLUID TEST CANCELLED ADULTERATED (adulterant/reason): SUBSTITUTEDREMARKS:XSignature of Medical Review Officer(PRINT) Medical Review Officer’s Name (First, MI, Last)////Date (Mo/Day/Yr)STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMENIn accordance with applicable federal requirements, my verification for the split specimen (if tested) is: TEST CANCELLED RECONFIRMED for: FAILED TO RECONFIRM for:REMARKS:XSignature of Medical Review Officer(PRINT) Medical Review Officer’s Name (First, MI, Last)COPY 2 - MEDICAL REVIEW OFFICER COPYDate (Mo/Day/Yr)

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM0000001ACCESSION NO.OMB No. 0930-0158SPECIMEN ID NO.NO.STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVEA. Employer Name, Address, I.D. No.B. MRO Name, Address, Phone No. and Fax No.C. Donor SSN, Employee I.D., or CDL State and No.D. Specify Testing Authority: HHS NRCSpecify DOT Agency: FMCSA FAA FRA FTA PHMSA USCGE. Reason for Test: Pre-employment Random Reasonable Suspicion/Cause Post Accident Return to Duty Follow-up Other (specify)F. Drug Tests to be Performed: THC, COC, PCP, OPI, AMP THC & COC Only Other (specify)G. Collection Site Address:Collector Contact Info: PhoneFaxOtherSTEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate). URINE ORAL FLUIDCOLLECTION: Split Single None Provided, Enter Remark.URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F? Yes No, Enter Remark Observed, Enter RemarkEach Device Within Expiration Date? Yes NoORAL FLUID: Split Type: Serial Concurrent Subdivided Volume Indicator(s) ObservedREMARKS:STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITYSPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this formwas collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.XSignature of Collector/(PRINT) Collector’s Name (First, MI, Last)AMPM/Date (Mo/Day/Yr)Name of Delivery ServiceTime of CollectionSTEP 5: COMPLETED BY DONORI certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube used was sealed with a tamper-evident sealin my presence; and that the information provided on this form and on the label affixed to each specimen bottle/tube is correct.XSignature of DonorDaytime Phone No. (Email address:)Evening Phone No. ()////Date (Mo/Day/Yr)(PRINT) Donor’s Name (First, MI, Last)Date of Birth(Mo/Day/Yr)After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may contact you to ask about prescriptions andover-the-counter medications you may have taken. Therefore, you may want to make a list of those medications for your own records. THIS LIST IS NOTNECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 5). – DO NOT PROVIDE THISINFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMENIn accordance with applicable federal requirements, my verification is: NEGATIVE POSITIVE for: DILUTE REFUSAL TO TEST because – check reason(s) below: ADULTERATED (adulterant/reason): SUBSTITUTED OTHER: URINE ORAL FLUID TEST CANCELLEDREMARKS:XSignature of Medical Review Officer(PRINT) Medical Review Officer’s Name (First, MI, Last)////Date (Mo/Day/Yr)STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMENIn accordance with applicable federal requirements, my verification for the split specimen (if tested) is: TEST CANCELLED RECONFIRMED for: FAILED TO RECONFIRM for:REMARKS:XSignature of Medical Review Officer(PRINT) Medical Review Officer’s Name (First, MI, Last)COPY 3 - COLLECTOR COPYDate (Mo/Day/Yr)

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM0000001ACCESSION NO.OMB No. 0930-0158SPECIMEN ID NO.STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVEA. Employer Name, Address, I.D. No.B. MRO Name, Address, Phone No. and Fax No.C. Donor SSN, Employee I.D., or CDL State and No.D. Specify Testing Authority: HHS NRCSpecify DOT Agency: FMCSA FAA FRA FTA PHMSA USCGE. Reason for Test: Pre-employment Random Reasonable Suspicion/Cause Post Accident Return to Duty Follow-up Other (specify)F. Drug Tests to be Performed: THC, COC, PCP, OPI, AMP THC & COC Only Other (specify)G. Collection Site Address:Collector Contact Info: PhoneFaxOtherSTEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate). URINE ORAL FLUIDCOLLECTION: Split Single None Provided, Enter Remark.URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F? Yes No, Enter Remark Observed, Enter RemarkEach Device Within Expiration Date? Yes NoORAL FLUID: Split Type: Serial Concurrent Subdivided Volume Indicator(s) ObservedREMARKS:STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITYSPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this formwas collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.XSignature of Collector(PRINT) Collector’s Name (First, MI, Last)/AMPM/Date (Mo/Day/Yr)Name of Delivery ServiceTime of CollectionSTEP 5: COMPLETED BY DONORI certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube used was sealed with a tamper-evident sealin my presence; and that the information provided on this form and on the label affixed to each specimen bottle/tube is correct.XSignature of DonorDaytime Phone No. (Email address:)Evening Phone No. ()////Date (Mo/Day/Yr)(PRINT) Donor’s Name (First, MI, Last)Date of Birth(Mo/Day/Yr)After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may contact you to ask about prescriptions andover-the-counter medications you may have taken. Therefore, you may want to make a list of those medications for your own records. THIS LIST IS NOTNECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 5). – DO NOT PROVIDE THISINFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMENIn accordance with applicable federal requirements, my verification is: NEGATIVE POSITIVE for: DILUTE REFUSAL TO TEST because – check reason(s) below: ADULTERATED (adulterant/reason): SUBSTITUTED OTHER: URINE ORAL FLUID TEST CANCELLEDREMARKS:XSignature of Medical Review Officer(PRINT) Medical Review Officer’s Name (First, MI, Last)////Date (Mo/Day/Yr)STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMENIn accordance with applicable federal requirements, my verification for the split specimen (if tested) is: TEST CANCELLED RECONFIRMED for: FAILED TO RECONFIRM for:REMARKS:XSignature of Medical Review Officer(PRINT) Medical Review Officer’s Name (First, MI, Last)COPY 4 - EMPLOYER COPYDate (Mo/Day/Yr)

Paper CCF: Back of Copy 1-4Electronic CCF: Separate PagePublic Burden StatementAn agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently validOMB control number. The OMB control number for this project is 0930-0158. Public reporting burden for this collection of information is estimatedto average: 5 minutes/donor; 4 minutes/collector; 3 mi

Test Facility (if different from above) : I certify that the specimen identified on this form was examined upon receipt, . Pre-employment Random Reasonable Suspicion/Cause Post Accident Return to Duty Follow-up Other (specify) Other (specify) Phone Fax Other / URINE ORAL FLUID RECONFIRMED FAILED TO RECONFIRM - REASON I certify that the split specimen identified on this form was